Int J Clin Exp Med 2015;8(10):17343-17352www.ijcem.com /ISSN:1940-5901/IJCEM0014794

Original ArticleTransversus abdominis plane block versus local anaesthetic wound infiltration for postoperative analgesia: A systematic review and meta-analysis

Qingduo Guo, Rui Li, Lixian Wang, Dong Zhang, Yali Ma

Department of Anesthesiology, Cangzhou City Central Hospital, No. 16, Xinhua West Road, Canal Zone, Cangzhou 061001, Hebei Province, China

Received August 20, 2015; Accepted October 13, 2015; Epub October 15, 2015; Published October 30, 2015

Abstract: Background: Transversus abdominis plane (TAP) block and local anaesthetic wound infiltration can provide effective pain relief at the wound site after surgery. However, the relative efficacy of two techniques for postoperative analgesia remains controversial. Methods: We searched PUBMED, EMBASE and CENTRAL databases for random-ized controlled trials (RCTs) comparing TAP block with wound infiltration for pain relief after surgery. The primary outcomes were pain scores at rest and on movement at 1, 8 and 24 hours postoperatively and cumulative morphine consumption over 24 hours. The secondary outcomes were time to first rescue analgesic, number of rescue analge-sic use and opioids-related side-effects. Results: Nine RCTs with a total of 500 participants were included. TAP block was associated with significant lower rest and dynamic pain scores at 8 hour [MD = -1.08, 95% CI (-1.89-0.26), P = 0.009] and 24 hour [MD = -0.83, 95% CI (-1.60, -0.06), P = 0.03] postoperatively than wound infiltration, but no significant difference was found at 1 hour [MD = -0.94, 95% CI (-1.97, 0.09), P = 0.08] postoperatively. In adults, TAP block significantly reduced 24-hour overall morphine consumption by 3.85 mg [MD = -3.85, 95% CI (-7.47, -0.22), P = 0.04] compared with wound infiltration. Subgroup analysis showed that adults received TAP block appeared to have lower rest pain scores at 24 hour than children (P = 0.008). Conclusion: TAP block provides superior analgesia compared with wound infiltration in the setting of a multimodal analgesic regimen. Subgroup analysis indicated that adults may have benefits additional to the analgesic effect than children.

Keywords: Acute pain, anaesthetic techniques, regional pain, regional blockade, TAP block

Introduction

Much of postoperative pain is derived from the surgical incision and visceral sites [1, 2]. Transversus abdominis plane (TAP) block, firstly described by Rafi et al in 2001, can block sen-sory nerve supply to the anterior abdominal wall by injecting local anaesthetics into the transversus abdominis fascial plane, which is located between the internal oblique and trans-versus abdominis muscles layers [3]. The TAP block, has shown effective pain relief after abdominal surgery [4, 5], hysterectomy surgery [6] and caesarean delivery [7, 8] compared with no intervention or placebo in previous meta- analyses.

Local anaesthetic infiltration into the surgical incision can relieve pain at the wound site after surgery, as part of multimodal analgesic approach [9-11]. This simple, safe, low-invasion

and low-cost technique, commonly performed by surgeon, is routinely conducted in many cen-ters for postoperative analgesia [2, 12, 13]. To data, the efficacy of TAP block versus wound infiltration on postoperative analgesia remains controversial. Therefore, the main objective of the current review is to compare the efficacy and safety of TAP block with wound infiltration for pain relief after surgery. The primary out-comes were pain scores at rest and on move-ment at 1, 8 and 24 hours postoperatively and cumulative morphine consumption over 24 hours. The secondary outcomes were time to first rescue analgesic, number of rescue anal-gesic use and opioids-related side-effects.

Methods

We followed the PRISMA [14] (Preferred Reporting Items for Systematic Reviews and

TAP vs LA wound infiltration for postoperative analgesia

17344 Int J Clin Exp Med 2015;8(10):17343-17352

Meta-Analyses) guidelines in the preparation of this review.

Literature search

The PUBMED, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized controlled trials (RCTs) that assessed the efficacy of postopera-tive pain relief comparing TAP block with local anaesthetic wound infiltration from database inception to 8 August 2014. The free text “TAP”, “transversus abdominis plane”, “transverse abdominis plane”, “infiltration”, “irrigation”, “instillation” were used in combination with the medical subject headings (MeSH), “abdominal muscles”, “abdominal wall”, “nerve block”, “anaesthetics, local”, “anesthesia, local”. No language restriction was used.

Inclusion and exclusion criteria

Inclusion criteria: full-text available RCTs, par-ticipants of any age or sex undergoing any type of elective or emergency surgery, comparing TAP block with wound infiltration analgesia, reported at least on pain scores or opioids con-sumption as postoperative pain outcomes. Exclusion criteria: comparing the combination

effect (TAP block + wound infiltration) with TAP or wound infiltration, partici-pants involved other nerve block.

Data collection

Two independent authors assessed the risk of bias of included studies using the Cochrane risk of bias tool. Five parameters (random-ization sequence genera-tion, allocation conceal-ment, blinding, incomplete outcome data, selective reporting) of each included studies were assessed as low, unclear or high risk of bias. Any discrepancies were resolved by discus-sion with the third author.

A data collection sheet was created to extract data

Figure 1. Flowchart of the literature search for included studies.

from eligible studies by two independent authors. Pain intensity reported on 0 to 100 mm scale with visual analog scale (VAS) or numeric rating scale (NRS) was converted to a 0 to 10 cm scale. Postoperative opioids con-sumption was converted to the equivalent dose of intravenous morphine as follow: tramadol (1:10) and fentanyl (10:1) [15]. Where data were presented as values other than mean and standard deviations, we tried to contact the author to obtain raw data. If it is not possible, data were converted to mean and standard deviation using previously described methodol-ogy and allow more studies to be included in the meta-analysis [16].

Statistical analysis

Dichotomous data were expressed as risk ratio (RR) with 95% confidence intervals (CI) and continuous variables are expressed as the mean difference (MD) with 95% CI. Difference was considered statistically significant if P<0.05, or 95% CI of RR excluded 1, or 95% CI excluded 0 for the MD. The I2 statistic was used to assess heterogeneity. If heterogeneity was significant (I2>50%), a random effects model was used; otherwise a fixed effects model was used. Analyses were performed using the

TAP vs LA wound infiltration for postoperative analgesia

17345 Int J Clin Exp Med 2015;8(10):17343-17352

Table 1. Characteristics of the included studies

Study No. of patients

Operation proce-dure and Anes-thetic technology

TAP block group Wound infiltration group Postoperative analgesia regimen Outcomes

Skjelsager 2013 [20]

48T 23W 25

Open radical retropu-bic prostatectomy un-der GA with propofol and remifentanil

Time: end of the surgeryLocalization: ultrasound guide bilateral LA: 20 ml ropivacaine 0.75% on each side

Time: end of the surgeryLocalization: subcutaneous by the operating surgeonLA: 40 ml ropivacaine 0.75%

Oral paracetamol 1000 mg /6 h, ibuprofen 600 mg/8 h, IV morphine and morphine PCA.

Pain scores at rest and on movement at 1, 2, 4, 6, 8, 20, 24 h, cumulative morphine consumption over 24 h, side-effects (nausea and sedation scores, number of vomiting).

Atim 2011 [19]

37T 18W 19

Total abdominal hys-terectomy under GA with sevoflurane

Time: after induction Localization: ultrasound guide bilateralLA: 20 ml bupivacaine 0.25% on each side

Time: end of the surgeryLocalization: skin and subcutane-ous tissues of the surgical incision siteLA: 20 ml bupivacaine 0.25%

Tramadol PCA and IM pethi-dine as rescue analgesic.

Pain scores at rest and on movement at 1, 2, 4, 6, 24 h, tramadol consumption at 1, 2, 4, 6, 24 h, number of rescue analgesic, rescue analgesic consumption.

Sahin 2013 [17]

Children 57T 29W 28

Unilateral inguinal hernia repair under GA with sevoflurane and N2O

Time: after inductionLocalization: ultrasound guideLA: 0.5 ml/kg levobupivacaine 0.25%

Time: during wound closureLocalization: between the external aponeurosis and the skin by the surgeonsLA: 0.2 ml/kg levobupivacaine 0.25%

Oral paracetamol 15 mg /kg/4 h and IV morphine 0.05 mg/kg as rescue analgesic

Pain scores at 1, 2, 4, 8, 12, 16, 20, 24 h, time of first analgesic use, number of analgesic uses, cumulative dose of paracetamol, side-effects (postoperative nausea, vomiting, hypotension, bradycardia and arrhythmia).

Ortiz 2012 [23]

74T 39W 35

Laparoscopic chole-cystectomy under GA with sevoflurane

Time: after inductionLocalization: ultrasound guided bilateralLA: 15 ml of ropivacaine 0.5% on each side

Time: preincisionalLocalization: infiltration of the 4 trocar insertion sitesLA: 20 ml of ropivacaine 0.5%

Oral hydrocodone 10 mg, acetaminophen 1000 mg/6 h and for severe pain IV morphine 4 mg/3 h

Pain scores at 0, 5, 10, 15, 20, 25 h, mor-phine consumption over 24 h, hydrocodone consumption over 24 h, the number of nausea.

Tolchard 2012 [22]

43T 21W 22

Laparoscopic chole-cystectomy under GA

Time: no mentionLocalization: ultrasound guidedLA: 1 mg/kg bupivacaine

Time: end of surgeryLocalization: port-site infiltration by surgeonLA: 1 mg/kg bupivacaine

IV fentanyl and oral weak opioids and non-opioid analgesic.

Pain scores at 0, 1, 2, 3, 4 h, fentanyl consumption in PACU, morphine tramadol and codeine consumption in ward, time to discharge.

Sandeman 2011 [2]

Children 87T 42W 45

Laparoscopic ap-pendicectomy under GA with sevoflurane and N2O

Time: after inductionLocalization: ultrasound guided bilateralLA: 0.5 mg/kg ropivacaine 0.2% on each side (2 mg/kg total of ropivacaine)

Time: at the port placementLocalization: port sites infiltration by the surgeonLA: 0.5 ml/kg of ropivacaine 0.2% (1 mg/kg total ropivacaine)

Morphine PCA and regular oral paracetamol 15 mg/kg.

Pain scores at 0, 4, 8, 12, 16 h, number of PCA use, morphine PCA consumption, time to first morphine use, time to first non-PCA analgesic, side-effects and time in the PACU and hospital.

Lorenzo 2014 [12]

Children 32T 16W 16

Unilateral open pyelo-plasty under GA with sevoflurane

Time: before incisionLocalization: ultrasound guidedLA: 0.4 ml/kg bupivacaine 0.25% with1:200000 epinephrine

Time: before incisionLocalization: regional field block by surgeon LA: 0.4 ml/kg bupivacaine 0.25% with 1:200000 epinephrine

IV morphine 0.05 mg/kg or ketorolac 0.5 mg/kg in the PACU and oral morphine, acetaminophen and ketoro-lac in the ward

Pain scores at PACU, number of rescue morphine use, morphine consumption in PACU and ward, side-effects and hospital stay.

Sivapurapu 2013 [21]

52T 26W 26

Lower abdominal gynecological surgery under GA with isoflu-rane and N2O

Time: after skin closureLocalization: ultrasound guided bilateralLA: 0.3 ml/kg bupivacaine 0.25% on each side

Time: after skin closureLocalization: surgical incisionLA: 0.6 ml/kg of 0.25% bupiva-caine.

IV morphine and morphine PCA.

Pain scores at 2, 4, 6, 24 h, time to first rescue analgesic, 24 h morphine consump-tion and side-effects (sedation scores at 2, 4, 6, 24 h and PONV incidence).

Aydogmus 2014 [18]

70T 35W 35

Caesarean section under spinal anesthe-sia with hyperbaric bupivacaine 10 mg plus fentanyl 20 μg

Time: after the surgical procedure was acomplishedLocalization: ultrasound guided bilateralLA: 20 ml (50 mg) levobupivacaine 0.25% on each side

Time: completion of the surgical procedureLocalization: subcutaneous wound site infiltration LA: 40 ml (100 mg) levobupiva-caine 0.25%

IM diclofenac sodium 75 mg and IV tramadol 50 mg.

Pain scores at 2, 6, first mobilization, 12, 24 h, time to first analgesic, intraopera-tive complication, side-effect and patient satisfaction.

GA = general anesthesia, TAP = transversus abdominis plane, IV = intravenous, IM = intramuscular, LA = local anaesthetic, PCA = patient controlled analgesia, PACU = post-anesthetic care unit, T = TAP block group, W = wound infiltration group.

TAP vs LA wound infiltration for postoperative analgesia

17346 Int J Clin Exp Med 2015;8(10):17343-17352

Review Manager (RevMan) version 5.1 (Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2011).

Results

Electronic search resulted in a total of 423stud-ies. After screening title and abstract, we retained 27 studies for further assessment. Finally, nine studies with 500 participants were included in this review. A flowchart of the litera-ture search for included studies is shown in Figure 1.

The sample size of most included studies was small, from 32 to 87 participants. Three stud-ies included a total of 176 child participants, mean or median ages ranged from 0.7 to 11 years [2, 12, 17]. Studies with adult partici-pants aged from mean or median of 28 to 63 years [18-23]. All nine studies involved elective surgery, including general [2, 17, 22, 23], uri-nary [12, 20], gynecology and obstetrics opera-tions [18, 19, 21]. Except one study performed caesarean section under spinal anesthesia [18], all studies involved general anesthesia [2, 12, 17, 19-23]. Both TAP block and wound infil-tration were performed using single-shot tech-nique in nine studies. The methodological qual-ity of four studies was low risk using the Cochrane risk of bias criteria [2, 12, 20, 23], and remaining five studies was moderate to high risk [17-19, 21, 22]. Three studies men-tioned “randomly”, but did not describe the method to generate a random sequence [17, 19, 22]. Allocation concealment was not men-tioned in two studies [18, 21]. In one study, the authors only mentioned that blinding began in

Table 2. The risk of bias of the included studies

StudyRadom

squence geeration

Allocation cocealment

Blinding of participants and

personnel

Blinding of outcome as-

sessment

Incomplete outcome

data

Selective reporting

Skjelsager 2013 [20] Low Low Low Low Low LowAtim 2011 [19] Unclear Low Low Low Low UnclearSahin 2013 [17] Unclear Low High High Low LowOrtiz 2012 [23] Low Low Low Low Low LowTolchard 2012 [22] Unclear Low Low Low Low LowSandeman 2011 [2] Low Low Low Low Low LowLorenzo 2014 [12] Low Low Low Low Low LowSivapurapu2013[21] Low Unclear Low Low Low LowAydogmus 2014 [18] Low Unclear Unclear Low Low Low

the recovery room and recovery room nurse was blinded, thus it was uncertain whether blinding was adequately performed [17]. Aydogmus et al mentioned “double-blinded study” and an investigator who collect data was blinded, but we did not know whether partici-pants were blinded [18]. The characteristics and risk of bias of the included studies are shown in details in Tables 1, 2.

Pain scores at rest at 1, 8 and 24 hour postop-eratively

Rest pain scores were reported at 1 hour post-operatively in five studies [17, 19, 20, 22, 23], at 2 hour in two studies [18, 21], at 4 hour in one study [22], at 6 hours in two studies [18, 19], at 8 hour in four studies [2, 17, 20, 23], at 16 hour in one study [2] and at 24 hours in six studies [17-21, 23]. Rest pain scores at 2 hours were combined into that at 1hour; pain scores at 4 and 6 hour were combined into that at 8 hours and pain scores at 16 hour were com-bined into that at 24 hours. TAP block showed significant lower rest pain scores at 8 hour [MD = -1.08, 95% CI (-1.89-0.26), P = 0.009] and 24-hour [MD = -0.83, 95% CI (-1.60, -0.06), P = 0.03] than wound infiltration, but no significant difference was found at 1 hour [MD = -0.94, 95% CI (-1.97, 0.09), P = 0.08]. However, there was significant heterogeneity in all analyses (for 1 hour: I2 = 89%; for 8 hour: I2 = 84%; for 24 hour: I2 = 93%) (Figure 2). Subgroup analysis of different participants didn’t reveal any differ-ence between children and adults in rest pain scores at 1 (P = 0.07) and 8 hour (P = 0.73). However, adults received TAP block appeared

TAP vs LA wound infiltration for postoperative analgesia

17347 Int J Clin Exp Med 2015;8(10):17343-17352

to have lower rest pain scores at 24 hour than children (P = 0.008) (Supplementary Figure 1). Comparing different types of surgery showed no significant difference between laparoscopic and non-laparoscopic surgery in rest pain scores at all end-points (for 1 hour: P = 0.48; for 8 hour: P = 0.16; for 24 hour: P = 0.17) (Supplementary Figure 2). TAP block performed at the end of surgery had marginally significant lower pain scores than that performed before incision at 24 hour postoperatively (P = 0.05), but no significant difference was found at 1 (P = 0.17) and 8 hour (P = 0.63) (Supplementary Figure 3).

Pain scores on movement at 1, 8 and 24 hour postoperatively

Dynamic pain scores were assessed at 1 hour postoperatively in two studies [19, 20], at 6

hour in one study [19], at 8 hour in one study [20] and at 24 hour in two studies [19, 20]. TAP block showed significant lower dynamic pain scores at 8 hour [MD = -0.66, 95% CI (-1.30, -0.03), P = 0.04] and 24 hour [MD = -0.93, 95% CI (-1.48, -0.39), P = 0.0007], but no significant difference was seen at 1 hour [MD = -1.01, 95% CI (-2.06, 0.04), P = 0.06] compared with wound infiltration (Figure 3). There was no significant heterogeneity in both analyses (for 1, 8 and 24 hour: I2 = 0%).

Cumulative morphine consumption over 24 hour

Five studies investigated 24-hour overall mor-phine consumption in adult participants [19-23]. TAP block reported significant reduction in 24-hour overall morphine consumption com-

Figure 2. Pain scores at rest at 1, 8 and 24 hour postoperatively.

TAP vs LA wound infiltration for postoperative analgesia

17348 Int J Clin Exp Med 2015;8(10):17343-17352

pared with wound infiltration [MD = -3.85, 95% CI (-7.47, -0.22), P = 0.04]. However, there was significant heterogeneity (I2 = 80%) (Figure 4). In one study with 57 children, TAP block con-sumed less oral paracetamol (mg/kg) over 24 hour than wound infiltration [MD = -33.30, 95% CI (-35.88, -30.72)] 17. In another children study reporting morphine consumption (μg/kg) at 0-8 hour and 8-16 hour as median and range found no significant difference between two groups [2]. In Lorenzo et al, more morphine (mg/kg) consumption was found in TAP block in PACU [MD = 0.04, 95% CI (0.01, 0.07)], but no significant difference was found with respect to overall morphine consumption (PACU + ward) [MD = 0.01, 95% CI (-0.04, 0.06)] in 32 children [12] The subgroup analysis of different types of surgery (laparoscopic vs non- laparoscopic sur-

gery, P = 0.77) and different time of TAP block performed (before incision vs end of surgery, P = 0.86) didn’t reveal any significant difference in cumulative morphine consumption over 24 hour (Supplementary Figures 4, 5).

Time to first rescue analgesic and number of rescue analgesic use

Time to first rescue analgesic (hour) assessed in four studies reported no significant differ-ence between TAP block and wound infiltration [MD = 2.55, 95% CI (-0.36, 5.46), P = 0.09] (Figure 5) [2, 17, 18, 21]. There was also no sig-nificant difference in number of rescue analge-sic use between two groups [RR = 0.95, 95% CI (0.56, 1.60), P = 0.85] (Figure 6) [12, 17-19]. However there was significant heterogeneity (for former: I2 = 84%; for later: I2 = 83%).

Figure 3. Pain scores on movement at 1, 8 and 24 hour postoperatively.

Figure 4. Cumulative morphine consumption over 24 hour (mg).

TAP vs LA wound infiltration for postoperative analgesia

17349 Int J Clin Exp Med 2015;8(10):17343-17352

Side-effects

Six studies reported incidence of postoperative nausea and vomiting (PONV), but only three studies present enough data for quantity analy-sis [12, 17, 18, 20, 21, 23]. Pool results showed no significant difference in PONV incidence between two groups [RR = 1.08, 95% CI (0.69, 1.71), P = 0.73, I2 = 0%] (Figure 7) [17, 20, 23]. In qualitative analysis, two of remaining three studies reported similar PONV incidence between two groups [12, 18], whereas one study showed significant lower PONV incidence in TAP block [21]. One study reporting sedation scores as median and interquartile distance showed no significant difference between TAP block and wound infiltration [20]. In another study, TAP block had significant lower sedation scores at 2 and 4 hour postoperatively than wound infiltration [21]. Two studies investigat-ed excessive sedation incidence reported no difference between two groups [2, 12].

Discussion

In this review, we included nine studies with a total of 500 participants comparing the postop-erative analgesia efficacy and safety of TAP block with wound infiltration.

TAP block had lower VAS pain scores at rest and on movement at 8 and 24 hour postopera-

tively, but no significant difference was found at 1 hour compared with wound infiltration. Our findings indicated that local anaesthetic wound infiltration may provide brief pain relief for less than 8 hour after surgery. Similarly, several pre-vious studies have shown that wound infiltra-tion only decrease immediate postoperative pain scores (in PACU or within several hours postoperatively) compared with placebo or no intervention in breast surgery [24, 25], hip arthroplasty [26], inguinal herniorrhaphy [27] and caesarean section [28]. In contrast, using catheter technique, both wound infiltration and TAP block can permit the delivery of continuous analgesia for a longer postoperative duration than single-shot block. In a meta-analysis included nine studies with 505 participants, continuous local anaesthetic wound catheter infiltration even was equivalent to epidural analgesia in terms of pain scores at rest and on movement at 24 and 48 hour after abdominal surgery [29] Therefore, future RCTs are needed to assess the analgesia efficacy of local anaes-thetic wound catheter infiltration after surgery.

Opioid requirement, a surrogate marker of pain, was lower by 3.85 mg in TAP block compared with wound infiltration over 24 hour in adults. However, the inconsistency in reporting cumu-lative opioid consumption precluded quantita-tive analysis in three studies with 176 children.

Figure 5. Time to first rescue analgesic (hour).

Figure 6. Number of rescue analgesic use.

TAP vs LA wound infiltration for postoperative analgesia

17350 Int J Clin Exp Med 2015;8(10):17343-17352

In qualitative analysis, two of three child stud-ies shown no significant difference in cumula-tive morphine consumption between two groups, but TAP block required significant less oral paracetamol than wound infiltration in study of Sahin et al. However, the methodologi-cal quality of Sahin et al was high risk, as the blinding was not likely to be adequately performed.

The PONV incidence and sedation scores were not significant difference between TAP block and wound infiltration in most included studies. Furthermore, no serious complications were reported following two groups in all nine stud-ies. TAP block is a less invasive method, but it is not without risk. With or without ultrasound guidance, reports of liver, bowl, nerve injuries and intraperitoneal and intravascular injection following TAP block have recently emerged [30-32]. Given the paucity of case reports about serious complications and popularity of TAP block, the incidence of catastrophic complica-tions seem extremely small.

There was significant heterogeneity among studies, likely due to different participants, dif-ferent types of surgery, different TAP block and wound infiltration technique, difference in dose and volume of local anaesthetic administrated and different postoperative analgesia. An attempt was made to pool the studies accord-ing to participants, types of surgery and the time TAP block performed. The subgroup analy-sis demonstrated that adults received TAP block showed more benefits from rest pain scores than children at 24 hour postoperative-ly, but no significant benefits were found at 1 and 8 hour postoperatively. We also found that TAP block performed at the end of surgery seems to provide marginally more effective pain relief than that performed before incision

at 24 hour postoperatively, and no significant difference was found at 1 and 8 hour postop-eratively. However, limited studies were con-ducted to subgroup analysis and there still was significant heterogeneity in most subgroup analysis. Therefore, the results from subgroup analysis may be biased and need to be inter-preted with caution.

Epidural analgesia is still considered as “gold-en standard” for postoperative analgesia, mostly because of its strong analgesic effects. However, the relative efficacy of TAP block and epidural analgesia remains controversial. TAP block was inferior to epidural analgesia with respect to postoperative analgesia in two stud-ies [33, 34]. On the contrary, comparable anal-gesia efficacy was found between TAP block and epidural analgesia in other two studies [35, 36]. Future studies with large sample size are necessary to compare TAP block with epidural analgesia for postoperative analgesia to reach a definite conclusion.

Conclusion

In conclusion, TAP block appeared to be supe-rior to local anaesthetic wound infiltration with respect to postoperative analgesia in the set-ting of a multimodal analgesic regimen. Adults may have benefits additional to the analgesic effect than children. It deserves to further assess the postoperative analgesia efficacy of TAP block versus epidural analgesia in the future study.

Disclosure of conflict of interest

None.

Address correspondence to: Qingduo Guo, Department of Anesthesiology, Cangzhou City Central Hospital, No. 16, Xinhua West Road, Canal

Figure 7. Postoperative nausea and vomiting (PONV) incidence.

TAP vs LA wound infiltration for postoperative analgesia

17351 Int J Clin Exp Med 2015;8(10):17343-17352

Zone, Cangzhou 061001, Hebei Province, China. E-mail: 55133319@qq.com

References

[1] Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. The transversus abdominis plane block provides effective postoperative analge-sia in patients undergoing total abdominal hys-terectomy. Anesth Analg 2008; 107: 2056-60.

[2] Sandeman DJ, Bennett M, Dilley AV, Perczuk A, Lim S, Kelly KJ. Ultrasound-guided transversus abdominis plane blocks for laparoscopic ap-pendicectomy in children: A prospective ran-domized trial. Br J Anaesth 2011; 106: 882-6.

[3] Rafi AN. Abdominal field block: A new approach via the lumbar triangle. Anaesthesia 2001; 56: 1024-6.

[4] Johns N, O’Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in ab-dominal surgery: A systematic review and me-ta-analysis. Colorectal Dis 2012; 14: e635-42.

[5] Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effec-tiveness of transversus abdominis plane block. J Clin Anesth 2011; 23: 7-14.

[6] Champaneria R, Shah L, Geoghegan J, Gupta JK, Daniels JP. Analgesic effectiveness of transversus abdominis plane blocks after hys-terectomy: A meta-analysis. Eur J Obstet Gyne-col Reprod Biol 2013; 166: 1-9.

[7] Abdallah FW, Halpern SH, Margarido CB. Trans-versus abdominis plane block for postopera-tive analgesia after Caesarean delivery per-formed under spinal anaesthesia? A systematic review and meta-analysis. Br J An-aesth 2012; 109: 679-87.

[8] Mishriky BM, George RB, Habib AS. Transver-sus abdominis plane block for analgesia after Cesarean delivery: A systematic review and meta-analysis. Can J Anaesth 2012; 59: 766-78.

[9] Feroci F, Kroning KC, Scatizzi M. Effectiveness for pain after laparoscopic cholecystectomy of 0.5% bupivacaine-soaked Tabotamp placed in the gallbladder bed: a prospective, random-ized, clinical trial. Surg Endosc 2009; 23: 2214-20.

[10] Bamigboye AA, Hofmeyr GJ. Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief. Cochrane Database Syst Rev 2009; CD006954.

[11] Rosaeg OP, Bell M, Cicutti NJ, Dennehy KC, Lui AC, Krepski B. Pre-incision infiltration with lido-

caine reduces pain and opioid consumption after reduction mammoplasty. Reg Anesth Pain Med 1998; 23: 575-9.

[12] Lorenzo AJ, Lynch J, Matava C, El-Beheiry H, Hayes J. Ultrasound Guided Transversus Ab-dominis Plane vs. Surgeon Administered Intra-operative Regional Field Infiltration with Bupi-vacaine for Early Postoperative Pain Control in Children Undergoing Open Pyeloplasty. J Urol 2014; 192: 207-13.

[13] Dingemann J, Kuebler JF, Wolters M, von Kam-pen M, Osthaus WA, Ure BM, Reismann M. Perioperative analgesia strategies in fast-track pediatric surgery of the kidney and renal pel-vis: lessons learned. World J Urol 2010; 28: 215-9.

[14] Moher D, Liberati A, Tetzlaff J, Altman DG. Pre-ferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010; 8: 336-41.

[15] Pereira J, Lawlor P, Vigano A, Dorgan M, Bruera E. Equianalgesic dose ratios for opioids. a criti-cal review and proposals for long-term dosing. J Pain Symptom Manage 2001; 22: 672-87.

[16] Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Meth-odol 2005; 5: 13.

[17] Sahin L, Sahin M, Gul R, Saricicek V, Isikay N. Ultrasound-guided transversus abdominis plane block in children: a randomised compar-ison with wound infiltration. Eur J Anaesthesiol 2013; 30: 409-14.

[18] Aydogmus MT, Sinikoglu SN, Naki MM, Ocak NB, Sanli N, Alagol A. Comparison of analgesic efficiency between wound site infiltration and ultrasound-guided transversus abdominis plane block after cesarean delivery under spi-nal anaesthesia. Hippokratia 2014; 18: 28-31.

[19] Atim A, Bilgin F, Kilickaya O, Purtuloglu T, Alan-bay I, Orhan ME, Kurt E. The efficacy of ultra-sound-guided transversus abdominis plane block in patients undergoing hysterectomy. Anaesth Intensive Care 2011; 39: 630-4.

[20] Skjelsager A, Ruhnau B, Kistorp TK, Kridina I, Hvarness H, Mathiesen O, Dahl JB. Transver-sus abdominis plane block or subcutaneous wound infiltration after open radical prostatec-tomy: A randomized study. Acta Anaesthesiol Scand 2013; 57: 502-8.

[21] Sivapurapu V, Vasudevan A, Gupta S, Badhe AS. Comparison of analgesic efficacy of trans-versus abdominis plane block with direct infil-tration of local anesthetic into surgical incision

TAP vs LA wound infiltration for postoperative analgesia

17352 Int J Clin Exp Med 2015;8(10):17343-17352

in lower abdominal gynecological surgeries. J Anaesthesiol Clin Pharmacol 2013; 29: 71-5.

[22] Tolchard S, Davies R, Martindale S. Efficacy of the subcostal transversus abdominis plane block in laparoscopic cholecystectomy: Com-parison with conventional port-site infiltration. J Anaesthesiol Clin Pharmacol 2012; 28: 339-43.

[23] Ortiz J, Suliburk JW, Wu K, Bailard NS, Mason C, Minard CG, Palvadi RR. Bilateral transversus abdominis plane block does not decrease postoperative pain after laparoscopic chole-cystectomy when compared with local anes-thetic infiltration of trocar insertion sites. Reg Anesth Pain Med 2012; 37: 188-92.

[24] Albi-Feldzer A, Mouret-Fourme EE, Hamouda S, Motamed C, Dubois PY, Jouanneau L, Jayr C. A double-blind randomized trial of wound and intercostal space infiltration with ropivacaine during breast cancer surgery: effects on chron-ic postoperative pain. Anesthesiology 2013; 118: 318-26.

[25] Vallejo MC, Phelps AL, Sah N, Romeo RC, Falk JS, Johnson RR, Keenan DM, Bonaventura MA, Edington HD. Preemptive analgesia with bupi-vacaine for segmental mastectomy. Reg Anes-th Pain Med 2006; 31: 227-32.

[26] Busch CA, Whitehouse MR, Shore BJ, MacDon-ald SJ, McCalden RW, Bourne RB. The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. Clin Orthop Relat Res 2010; 468: 2152-9.

[27] Bays RA, Barry L, Vasilenko P. The use of bupi-vacaine in elective inguinal herniorrhaphy as a fast and safe technique for relief of postopera-tive pain. Surg Gynecol Obstet 1991; 173: 433-7.

[28] Trotter TN, Hayes-Gregson P, Robinson S, Cole L, Coley S, Fell D. Wound infiltration of local an-aesthetic after lower segment caesarean sec-tion. Anaesthesia 1991; 46: 404-7.

[29] Ventham NT, Hughes M, O’Neill S, Johns N, Brady RR, Wigmore SJ. Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal sur-gery. Br J Surg 2013; 100: 1280-9.

[30] Frigon C, Mai R, Valois-Gomez T, Desparmet J. Bowel hematoma following an iliohypogastric-ilioinguinal nerve block. Paediatr Anaesth 2006; 16: 993-6.

[31] Jankovic Z, Ahmad N, Ravishankar N, Archer F. Transversus abdominis plane block: how safe is it? Anesth Analg 2008; 107: 1758-9.

[32] Lancaster P, Chadwick M. Liver trauma sec-ondary to ultrasound-guided transversus ab-dominis plane block. Br J Anaesth 2010; 104: 509-10.

[33] Wu Y, Liu F, Tang H, Wang Q, Chen L, Wu H, Zhang X, Miao J, Zhu M, Hu C, Goldsworthy M, You J, Xu X. The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intrave-nous opioid analgesia after radical gastrecto-my. Anesth Analg 2013; 117: 507-13.

[34] Wahba SS, Kamal SM. Analgesic efficacy and outcome of transversus-abdominis plane block versus low thoracic-epidural analgesia after laparotomy in ischemic heart disease pa-tients. J Anesth 2013; 28: 517-23.

[35] Rao Kadam V, Van Wijk RM, Moran JI, Miller D. Epidural versus continuous transversus ab-dominis plane catheter technique for postop-erative analgesia after abdominal surgery. An-aesth Intensive Care 2013; 41: 476-81.

[36] Niraj G, Kelkar A, Hart E, Horst C, Malik D, Yeow C, Malik D, Yeow C, Singh B, Chaudhri S. Comparison of analgesic efficacy of four-quad-rant transversus abdominis plane (TAP) block and continuous posterior TAP analgesia with epidural analgesia in patients undergoing lap-aroscopic colorectal surgery: an open-label, randomised, non-inferiority trial. Anaesthesia 2014; 69: 348-55.

TAP vs LA wound infiltration for postoperative analgesia

1

Supplementary Figure 1. Subgroup analysis of different participants (adults vs children) in rest pain scores at 1 hour (A), 8 hour (B) and 24 hour (C) postoperatively.

TAP vs LA wound infiltration for postoperative analgesia

2

Supplementary Figure 2. Subgroup analysis of different types of surgery (non-laparoscopic vs laparoscopic) in rest pain scores at 1 hour (A), 8 hour (B) and 24 hour (C) postoperatively.

TAP vs LA wound infiltration for postoperative analgesia

3

Supplementary Figure 3. Subgroup analysis of different time TAP block performed (before incision vs end of sur-gery) in rest pain scores at 1 hour (A), 8 hour (B) and 24 hour (C) postoperatively.

TAP vs LA wound infiltration for postoperative analgesia

4

Supplementary Figure 4. Subgroup analysis of different types of surgery (non-laparoscopic vs laparoscopic) in cu-mulative morphine consumption over 24 hour.

Supplementary Figure 5. Subgroup analysis of different time TAP block performed (before incision vs end of sur-gery) in cumulative morphine consumption over 24 hour.